Healthcare Provider Details

I. General information

NPI: 1033832308
Provider Name (Legal Business Name): CORINNE BOAK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/22/2022
Last Update Date: 09/22/2022
Certification Date: 09/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

35501 MOUND RD
STERLING HEIGHTS MI
48310-4724
US

IV. Provider business mailing address

10680 INDIANOLA RD
WHITMORE LAKE MI
48189-9747
US

V. Phone/Fax

Practice location:
  • Phone: 855-445-4554
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number4704331055
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: